This population-based, prospective, cohort study was designed to determine the population incidence and outcomes of pediatric acute lung injury.
Between 1999 and 2000, 1 year of screening was ...performed at all hospitals admitting critically ill children in King County, Washington. County residents 0.5 to 15 years of age who required invasive (through endotracheal tube or tracheostomy) or noninvasive (through full face mask) mechanical ventilation, regardless of the duration of mechanical ventilation, were screened. From this population, children meeting North American-European Consensus Conference acute lung injury criteria were eligible for enrollment. Postoperative patients who received mechanical ventilation for <24 hours were excluded. Data collected included the presence of predefined cardiac conditions, demographic and physiological data, duration of mechanical ventilation, and deaths. US Census population figures were used to estimate incidence. Associations between outcomes and subgroups identified a priori were assessed.
Thirty-nine children met the criteria for acute lung injury, resulting in a calculated incidence of 12.8 cases per 100000 person-years. Severe sepsis (with pneumonia as the infection focus) was the most common risk factor. The median 24-hour Pediatric Risk of Mortality III score was 9.0, and the mean +/- SD was 11.7 +/- 7.5. The hospital mortality rate was 18%, lower than that reported previously for pediatric acute lung injury. There were no statistically significant associations between age, gender, or risk factors and outcomes.
We present the first population-based estimate of pediatric acute lung injury incidence in the United States. Population incidence and mortality rates are lower than those for adult acute lung injury. Low mortality rates in pediatric acute lung injury may necessitate clinical trial outcome measures other than death.
OBJECTIVES:Administration of eicosapentaenoic acid and docosahexanoic acid, omega-3 fatty acids in fish oil, has been associated with improved patient outcomes in acute lung injury when studied in a ...commercial enteral formula. However, fish oil has not been tested independently in acute lung injury. We therefore sought to determine whether enteral fish oil alone would reduce pulmonary and systemic inflammation in patients with acute lung injury.
DESIGN:Phase II randomized controlled trial.
SETTING:Five North American medical centers.
PATIENTS:Mechanically ventilated patients with acute lung injury ≥18 yrs of age.
INTERVENTIONS:Subjects were randomized to receive enteral fish oil (9.75 g eicosapentaenoic acid and 6.75 g docosahexanoic acid daily) or saline placebo for up to 14 days.
MEASUREMENTS AND MAIN RESULTS:Bronchoalveolar lavage fluid and blood were collected at baseline (day 0), day 4 ± 1, and day 8 ± 1. The primary end point was bronchoalveolar lavage fluid interleukin-8 levels. Forty-one participants received fish oil and 49 received placebo. Enteral fish oil administration was associated with increased serum eicosapentaenoic acid concentration (p < .0001). However, there was no significant difference in the change in bronchoalveolar lavage fluid interleukin-8 from baseline to day 4 (p = .37) or day 8 (p = .55) between treatment arms. There were no appreciable improvements in other bronchoalveolar lavage fluid or plasma biomarkers in the fish oil group compared with the control group. Similarly, organ failure score, ventilator-free days, intensive care unit-free days, and 60-day mortality did not differ between the groups.
CONCLUSIONS:Fish oil did not reduce biomarkers of pulmonary or systemic inflammation in patients with acute lung injury, and the results do not support the conduct of a larger clinical trial in this population with this agent. This experimental approach is feasible for proof-of-concept studies evaluating new treatments for acute lung injury.
Objectives
To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.
Design
Multisite randomized controlled trial from April 2009 to March 2013.
Setting
...Three New York hospitals.
Participants
Individuals with hip fracture (N = 161).
Intervention
Participants were randomized to receive an ultrasound‐guided, single‐injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82).
Measurements
Pain (0–10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects.
Results
Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3–232 vs 100.0 feet, 95% CI = 65.1–134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6–11.0) vs 9.1 (95% CI = 8.2–10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents.
Conclusion
Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
The American College of Emergency Physicians (ACEP) and the Council of Emergency Medicine Residency Directors (CORD) were invited to contribute to the 2016 Accreditation Council for Graduate Medical ...Education's (ACGME)
. We describe the joint process used by ACEP and CORD to capture the opinions of emergency medicine (EM) educators on the ACGME clinical and educational work hour standards, formulate recommendations, and inform subsequent congressional testimony.
In 2016 our joint working group of experts in EM medical education conducted a consensus-based, mixed-methods process using survey data from medical education stakeholders in EM and expert iterative discussions to create organizational position statements and recommendations for revisions of work hour standards. A 19-item survey was administered to a convenience sample of 199 EM residency training programs using a national EM educational listserv.
A total of 157 educational leaders responded to the survey; 92 of 157 could be linked to specific programs, yielding a targeted response rate of 46.2% (92/199) of programs. Respondents commented on the impact of clinical and educational work-hour standards on patient safety, programmatic and personnel costs, resident caseload, and educational experience. Using survey results, comments, and iterative discussions, organizational recommendations were crafted and submitted to the ACGME.
EM educators believe that ACGME clinical and educational work hour standards negatively impact the learning environment and are not optimal for promoting patient safety or the development of resident professional citizenship.
Abstract Background Hip fractures are a painful condition commonly encountered in the emergency department (ED). Older adults in pain often receive suboptimal doses of analgesics, particularly in ...crowded EDs. Nerve blocks have been utilized by anesthesiologists to help control pain from hip fractures postoperatively. The use of nerve stimulator with ultrasonographic guidance has increased the safety of this procedure. Objectives We instituted a pilot study to assess the ability of Emergency Medicine (EM) resident physicians to effectively perform this procedure after a didactic and demonstration session. Methods First-year EM residents from three urban training programs underwent a 1-h didactic and hands-on training session on the femoral nerve block (FNB) procedure. A written pretest was used to assess baseline knowledge; it was administered again (with test items randomized) at 1 and 3 months post training session. A critical actions checklist (direct observation of procedure steps via simulated patient encounter) was used to assess the residents after the training session and again at 3 months. Results A total of 38 EM residents were initially evaluated. Thirty-three successfully completed 1-month and 3-month written test evaluations; 30 completed all written and direct observation evaluations. The mean written pretest scores were 66% (SD 9); post-test 92% (SD 5), 1-month 74% (SD 8), and 3-month 75% (SD 9). After initial training, 37 of 38 (97%) residents demonstrated competency (completing ≥ 15 of 19 critical actions) in the FNB procedure determined via direct observation. At 3 months, 25 of 30 residents (83%) continued to retain 85% of their initial critical action skills, and 3 of 30 (10%) saw an improvement in their proficiency. Conclusion A 1-h training and demonstration module yielded high competency rates in residents performing critical actions related to the FNB; these skills were well maintained at 3 months. An ongoing study will attempt to correlate this competency with procedures performed on patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
In 2012, the Accreditation Council for Graduate Medical Education (ACGME) designated ultrasound (US) as one of 23 milestone competencies for emergency medicine (EM) residency graduates. With ...increasing scrutiny of medical educational programs and their effect on patient safety and health care delivery, it is imperative to ensure that US training and competency assessment is standardized. In 2011, a multiorganizational committee composed of representatives from the Council of Emergency Medicine Residency Directors (CORD), the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine (SAEM), the Ultrasound Section of the American College of Emergency Physicians (ACEM), and the Emergency Medicine Residents' Association was formed to suggest standards for resident emergency ultrasound (EUS) competency assessment and to write a document that addresses the ACGME milestones. This article contains a historical perspective on resident training in EUS and a table of core skills deemed to be a minimum standard for the graduating EM resident. A survey summary of focused EUS education in EM residencies is described, as well as a suggestion for structuring education in residency. Finally, adjuncts to a quantitative measurement of resident competency for EUS are offered.
Resumen
CORD‐AEUS: Documento de Consenso Para el Proyecto de Objetivos por Áreas Respecto a la Ecografía de Urgencias y Emergencias
En 2012, el Accreditation Council for Graduate Medical Education (ACGME) designó la ecografía (ECO) como una de las 23 competencias de los objetivos por áreas para los graduados tras la residencia en medicina de urgencias y emergencias (MUE). Con el incremento de los exámenes de los programas formativos en medicina y sus efectos en la atención y la seguridad del paciente, es obligado asegurar que la formación y la valoración de la competencia en ECO estén estandarizadas. En 2011, se formó un comité compuesto por varias organizaciones de representantes del Council of Residency Directors for Emergency Medicine, el Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine, la Ultrasound Section del American College of Emergency Physicians y la Emergency Medicine Residents Association para sugerir la valoración de la competencia estándar en ecografía para los residentes de urgencias y emergencias y redactar un documento que abordara los objetivos por áreas del ACGME. Este artículo contiene una perspectiva histórica de la formación de los residentes en ecografía de urgencias y emergencias, y una tabla de habilidades básicas consideradas el mínimo estándar a alcanzar cuando un residente se gradúa en MUE. Se describe una encuesta resumen de la formación en ecografía de urgencias y emergencias en la residencia de MUE, así como sugerencias para estructurar la formación durante ella. Finalmente, se recogen documentos anexos para una medida cuantitativa de la competencia del residente en ecografía de urgencias y emergencias.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
The prevalence of burnout and depression are high among surgical trainees. This study examined the impact of program-driven initiatives to improve surgical trainee wellness.
A survey was administered ...to residents and fellows at all surgical training programs across an urban academic health system. The survey measured burnout, depressive symptoms, and perceptions of program-driven wellness initiatives.
The response rate was 44% among 369 residents. Of these, 63.2% screened positively for burnout, and 36.7% for depression. Residents who were burned out were more likely to work >80 h per week, have greater clerical duties, and miss educational activities more frequently. Conversely, having opportunities for wellness activities, dedicated faculty and housestaff wellness champions, and assistance with clerical burden were all associated with lower rates of burnout and depression.
The presence of wellness support was associated with better outcomes, suggesting the value of initiatives to manage workload and support the well-being of surgical resident physicians.
•Burnout and depressive symptoms are prevalent among surgical trainees.•Training program-driven wellness initiatives can support trainee well-being.•Depression may be difficult to predict from individual- and program-level factors.
The present study measured the prevalence of burnout and depressive symptoms among surgical residents and fellows across an urban academic health system. Prevalence of burnout and depression were 63.2% and 36.7%, respectively. Greater workload appeared to be correlated with increased burnout and depression, whereas the presence of program-driven wellness initiatives was associated with better wellness outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Implementation of new ventilatory strategies such as lung-protective ventilation for ARDS will require a multidisciplinary approach with considerable physician and respiratory therapy (RT) ...interaction. One of the key factors in this communication is complete and accurate RT documentation of ventilator settings. Few studies have explored the quality and variability of this documentation.
Population-based cross-sectional study.
Seventeen adult hospitals in King County, WA.
We compared the blank RT ICU flow sheet for each institution to the 1992 American Association for Respiratory Care (AARC) clinical practice guidelines (CPGs) for patient-ventilator system checks. We interviewed RT managers at each hospital about their practices. Finally, we reviewed selected charts of patients with acute lung injury (ALI) or ARDS from each hospital to evaluate the documentation.
We found substantial variability in RT documentation practices and in their extent of compliance with the AARC CPGs. Only 15 of 52 items recommended by the AARC CPGs were included on blank RT flow sheets of every hospital in our study, and only 26 of 52 items were found on charts of ALI/ARDS patients at most hospitals (ie, ≥ 10 of 17 hospitals). Only 10 of 17 RT department managers reported using the AARC CPGs as a basis for their documentation policies. Items necessary for the implementation of lung-protective ventilation for ALI/ARDS patients were recorded inconsistently and were not included in the AARC CPGs. Plateau pressure was found on all reviewed charts of ALI/ARDS patients at only 10 of 17 hospitals.
Considerable variability exists in RT documentation practices. We suggest that new guidelines be developed for documenting the care of patients receiving mechanical ventilation, in light of recent data on ventilator weaning and the management of ALI/ARDS, and that their effect on practice and outcomes be evaluated.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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